Appeals Analyst

Wellfleet; Springfield (MA); On-site; USD 52,000 - 58,000; Full time

Job summary

Wellfleet is seeking an experienced Appeals Analyst to support the Legal team. This role focuses on timely review of all appeals and complaints across product lines, ensuring adherence to policy language and regulatory timeframes.

The ideal candidate will have an associate degree and 3+ years of relevant experience, strong writing and communication skills, and solid knowledge of state regulations and medical coding terminology.

Qualifications

• Associate’s Degree and 3+ years relevant work experience or equivalent combination of education and experience.
• Detail oriented with strong communication skills.
• Strong organizational skills, including thorough and complete follow-up to all time-sensitive items.
• Excellent written and verbal communication skills.
• Excellent interpersonal skills. Commitment to a team-oriented office environment.
• Internet savvy and proficient with Microsoft Word, Outlook, and Excel.
• Ability to interpret policy language.
• Demonstrated business writing proficiency in accordance with regulatory requirements, internal policies, and claim events.
• Strong aptitude and familiarity with medical coding and medical terminology.
• Strong understanding and familiarity of the different state regulations.
• Must demonstrate excellent written communication skills
• Detail oriented problem solver with good time management skills.

Responsibilities

• Analyze and respond to appeals and Department of Insurance complaints in accordance with policy language and regulatory requirements.
• Prepare and send acknowledgements and correspondence within deadlines.
• Gather, review, and maintain documentation to support appeal and complaint responses.
• Conduct research and analysis using approved guidelines and tools.
• Monitor requirements with Compliance and other departments and support process improvements.
• Follow up on inquiries, requests, and tasks through to completion.
• Maintain knowledge of products, systems, and workflows including LuminX, Spartacus, and Microsoft Office.
• Communicate with carriers and internal departments as needed, including escalated appeal inquiries.
• Follow management-approved workflows and make independent decisions based on available data.
• Manage multiple priorities and meet deadlines.
• Provide back-up support to the Appeals Manager including reporting requests and staff onboarding.

Skills

Associate degree

3+ years experience

Detail oriented

Strong communication

Policy language interpretation

Medical coding terminology

State regulations familiarity

Time management

Business writing proficiency

Education

Associate's Degree

Tools

LuminX

Spartacus

Microsoft Office

Job description

Wellfleet, a Berkshire Hathaway company, delivers customer-centric accident and health insurance, with quality service and uncompromising ethics. Wellfleet works to protect people against risk throughout every stage of life – from grade school to college to the workplace.

Founded in 1993 as Consolidated Health Plans (CHP), Wellfleet, headquartered in Springfield, Mass., is one of the nation’s leading providers of health and accident insurance products to the higher education market.

We are seeking an experienced Appeals Analyst to support the Wellfleet Legal team. If that's you, come join our growing team!

The ideal candidate in this position will be responsible for the timely review of all Appeals and Complaints for all product lines administered by Wellfleet.

In this role, you will…

• Analyze and respond to appeals and Department of Insurance complaints in accordance with policy language, applicable regulatory requirements, and required state and federal timeframes.
• Prepare and send required acknowledgements and correspondence within applicable deadlines.
• Gather, review, and maintain documentation needed to support appeal and complaint responses, including accurate appeal-system documentation.
• Conduct research and analysis using approved guidelines and tools, with consideration of accreditation standards, state and federal regulatory requirements, legal requirements, benefits, COB, ACA, HIPAA Privacy, and claims payment rules.
• Work with Compliance and other departments to monitor requirements, identify trends, and support process improvements.
• Follow up on inquiries, requests, and task assignments through completion.
• Maintain working knowledge of new and existing products, systems, and workflows, including LuminX, Spartacus, and Microsoft Office.
• Communicate with carriers and internal departments as needed, including escalated appeal inquiries.
• Follow management-approved workflows and make independent decisions based on available research and documentation.
• Manage multiple priorities and meet required deadlines.
• Provide back-up support to the Appeals Manager, including regulatory, carrier, and interdepartmental reporting requests; staff onboarding, training, and refresher training; and review of new appeals legislation to support updates to departmental processes and letters.
• Perform other duties as assigned.

We are looking for candidates with…

• Associate’s Degree and 3+ years relevant work experience or equivalent combination of education and experience.
• Detail oriented with strong communication skills.
• Strong organizational skills, including thorough and complete follow-up to all time-sensitive items.
• Excellent written and verbal communication skills.
• Excellent interpersonal skills. Commitment to a team-oriented office environment.
• Internet savvy and proficient with Microsoft Word, Outlook, and Excel.
• Ability to interpret policy language.
• Demonstrated business writing proficiency in accordance with regulatory requirements, internal policies, and claim events.
• Strong aptitude and familiarity with medical coding and medical terminology.
• Strong understanding and familiarity of the different state regulations.
• Must demonstrate excellent written communication skills
• Detail oriented problem solver with good time management skills.

Why Wellfleet?

Here at Wellfleet, we foster a culture of growth that enables engaged and high-performing professionals to be empowered to deliver our mission and vision.

Our employees are a team devoted to providing customer service that exceeds expectations of our members and clients. Successful team members continually look for ways to improve product delivery and value.

Wellfleet offers a competitive compensation package and comprehensive benefits package including life, health and dental, vision, 401K retirement plan, short- and long-term disability coverage, flexible/dependent care spending account, tuition reimbursement, and business casual dress.

General:

Wellfleet is part of the MedPro Group family. As such, all Wellfleet team members are employees of MedPro Group Inc. We are an Equal Opportunity Employer. The annual gross base salary range is $52,000 to $58,000. This range anticipates the low and high end of the salary for this position. Actual salaries will vary and are based on factors such as a candidate’s qualifications, skills and competencies. Salary is one component of Wellfleet’s total compensation and benefits package, which includes medical, vision and dental insurance options, life and accident insurance, 401(k), and short-term and long-term disability insurance. For a more detailed overview, visit our careers website at: wellfleetinsurance.com/about/careers.